Periodontics Section - Bone Replacement Graft
|Topic: Bone Replacement
||Date of Origin: January 2000
||Policy No: 36
|Last Reviewed: January 2015
||Last Revised: January 2015
|Approved: January 2015
This Dental Policy has been developed through consideration of
generally accepted standards of dental practice, review of dental literature,
dental necessity, and as appropriate, government approval.
Benefit determinations should be based
in all cases on the applicable contract language.
To the extent there are any conflicts between these guidelines and the
contract language, the contract language will control.
The purpose of dental policy is to provide a guide to coverage. Dental
policy is not intended to dictate to providers how to practice dentistry.
Providers are expected to exercise their clinical judgment in providing
the most appropriate care.
Bone replacement graft – first site in
This procedure involves the use of grafts to stimulate periodontal regeneration when the disease process has led to a deformity of the bone. This procedure does not include flap entry and closure, wound debridement, osseous contouring, or the placement of biologic materials to aid in osseous tissue regeneration or barrier membranes. Other separate procedures delivered concurrently are documented with their own unique codes.
Bone replacement graft – each additional
site in quadrant (D4264):
This procedure involves the grafts to stimulate periodontal regeneration when the disease process has led to a deformity of the bone. This procedure does not include flap entry and closure, wound debridement, osseous contouring, or the placement of biologic materials to aid in osseous tissue regeneration or barrier membranes. This procedure is performed concurrently with one or more bone replacement grafts to document the number of sites involved.
Biologic materials to aid in soft and osseous tissue
Biologic materials may be used alone or with other regenerative substrates such as bone and barrier membranes, depending upon their formulation and the presentation of the periodontal defect. Does not include surgical entry and closure, wound debridement, osseous contouring, or the placement of graft materials and/or barrier membranes.
Procedures are in accordance with generally
accepted standards of dental practice.
Process to contract benefits.
*Definition of "site" precedes code
Bone replacement grafts function primarily as a defect filler and may have a slight potential for periodontal regeneration.
Patient selection criteria:
- Intrabony (walled) defects or furcations.
- Radiographic or charting evidence of vertical bone deformity.
- Grafts D4263, D4264 are used in treatment of teeth in site as opposed to use of grafts for augmentation of general bone form or immediate fill of extraction sockets (D7950, D7955). If the involvement of the extracted tooth socket has compromised adjacent teeth, grafting in socket to aid reconstruction of the periodontium may be covered.
- May be performed in conjunction with D4240, D4260, D4266, D4267
- Biologic materials to aid regeneration are covered (D4265).
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